Cervical Case 1
An otherwise healthy 33 year-old woman, complains of ongoing neck pain since a hyperextension injury in a car accident 6 months earlier. There was no direct impact in the accident, no loss of consciousness and no memory loss. Initial pain onset was the day following the accident. The initial pain was felt in the right neck and upper trapezius with occipital headache. Nausea, lightheadedness and unsteadiness were experienced the day after the accident. This non-vertiginous dizziness was initially present on every neck movement but after a week or so, it was only felt on right rotation combined with extension. She was put into a soft cervical collar for a week by her GP and given analgesics. She continued to work as a medical secretary. The pain eased off somewhat during the next three weeks and by six weeks she was almost painfree, except for some mild soreness in the right upper cervical spine. The dizziness was gone by three weeks post-accident.
She continued to have mild discomfort in the right suboccipital area intermittently but nothing that interfered with function and she did not feel it was of sufficient intensity to warrant treatment other than aspirin as required. This state of affairs continued until three months ago when the suboccipital pain increased in intensity and was accompanied by type 2 dizziness (giddiness and nausea). The first episode of recurrent pain lasted two weeks and the second six weeks. She had no previous physical treatment, each time being treated by her physician employer with analgesics, muscle relaxants and anti-inflammatories. .
This, the third episode, started four days earlier. She complains of right-sided upper cervical and occipital pain and type 2 dizziness for the last three days
What are you thinking at this point and how will you proceed with the examination of this patient.
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Cervical Case 1 Discussion
The important aspect of this case is to make sure that the dizziness has a benign etiology. After this has been established then it is reasonable to look at the musculoskeletal dysfunction.
Among the possible causes this lady's dizziness are:
* Cerebral or brainstem concussion
* Labyrinthine concussion
* Brainstem damage
* Cervical joint damage
* Vertebrobasilar ischemia
Cerebral or brainstem concussion as a cause of her dizziness is very unlikely as there was no history of being knocked unconscious or of amnesia . Also, the dizziness is intermittent with long periods between episodes. Medication is a possible cause and questions as to the association between the ingestion of her medication and her dizziness are necessary. However, she was taking analgesics and anti-inflammatories during the acute stage and the dizziness improved, so this is an unlikely etiology.
From her history, there was no ear pain, pops or clicks and no immediate dizziness and the dizziness was not of the vertigo type. This tends to move the diagnosis away from benign paroxysmal positional dizziness from labyrinthine concussion, although they are still possibilities. However, the periods between episodes of pain are free from dizziness. The dizziness seems to be associated with her cervical pain and if labyrinthine concussion was the source, then there should be dizziness present at times other than when the neck is painful. That the dizziness is related to her neck pain getting worse and better as her neck pain does, would suggest cervical joint causes.
Vertebrobasilar insufficiency as a cause is unlikely. There is no good reason for the episodic nature of the symptoms if the artery was the cause. And there are no symptoms other than the type 2 dizziness that would suggest other cranial nerve involvement but this consideration is marginal as many cranial nerves when injured do not cause symptoms that are obvious to the patient. But as cervical rotation combined with extension is the movement that reproduces her dizziness and is also the most stressful movements for a single vertebral artery this diagnosis cannot be excluded on the history alone.
Most likely cause of the dizziness is cervical joint dysfunction, but the main concern is with the condition of the vertebral artery
Investigate the most serious symptoms first, the dizziness. Assume that it is neurovascular in origin and go from there.
1. Cranial nerve and long tract tests (the latter if the cranial nerves are positive)
2. Craniovertebral ligamentous stress tests (transverse (anterior shear and Sharp-Purser, and alar)
3. Dizziness reproduction tests (leave right rotation/extension until last)
4. Differentiation tests (body rotation under the right rotated/extended head and Hautard's test)
If everything is clear with above examination, proceed to the remainder of the musculoskeletal examination, the upper quadrant scan and then the biomechanical examination.
The cranial nerve examination was negative except that during ocular tracking, the patient experienced mild vertigo on looking to the right and upwards. The ligament stress tests were negative. The results of the dizziness tests were:
Reproduction test for right rotation/extension produced mild lightheadedness
Body rotation test - left rotation under the extended head produced mild lightheadedness
Hautard's test was negative
Extension and right rotation were painful and slightly limited. The other movements were full range and painfree.
There were no signs of neurological deficits. There were no dural signs and the upper limb tension tests were painfree.
No working diagnosis was possible from these results so a biomechanical examination was carried out. The passive and accessory intervertebral movement tests for combined extension and left side flexion were positive at the right C2/3 zygopophyseal joint with a pathomechanical (jammed) end feel.
Do these results strengthen or weaken the postulate that the dizziness is caused by the cervical joints. What is your treatment plan.
Cervical Case 1 Discussion
The results of the objective examination strengthen the hypothesis that the likeliest cause of the dizziness is cervical joint dysfunction. The most likely source is the C2/3 cervical joint extension hypomobility (subluxed or jammed in flexion). The upper cervical levels are intimately associated with balance and experimentally have been shown to cause dizziness when dysfunctional.
Best treatment is manipulation, second best, non-rhythmic mobilization either followed by segmental stability testing and stability therapy if appropriate. Whether stable of unstable, the neck must be treated with functional re-education movement exercises.
The patient should be assessed for balance as this seems to be affected in many long-term cervical injury cases and if disequilibrium is found, exercises to optimize balance given.